Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Nspire Healthcare Kendall during CMS and state inspections, most recent first.
A facility conducted a trial removal of restraints for a resident without a physician's order. The resident, diagnosed with cerebral infarction, used a soft safety belt in a wheelchair to prevent falls. The trial was done to assess fall risk changes, but the physician was informed only after completion. The MDS coordinator did not code the restraint due to the trial, and the care plan lacked documentation of the trial. The ADON noted the absence of a specific quality of care policy.
A resident was found with four disposable shaving razors on their nightstand, contrary to the facility's policy that prohibits residents from keeping razors in their rooms. The resident, who was independent in personal hygiene and had no cognitive impairment, stated that staff provided the razors. The facility's policy requires razors to be given by CNAs and disposed of in a sharps container after use, which was not followed in this instance.
A resident with a physician's order for continuous oxygen was observed without oxygen in progress, despite a care plan indicating the need for continuous humidified oxygen due to respiratory issues. Staff interviews revealed a lack of awareness and communication about the resident's oxygen needs, with a registered nurse noting the resident's confusion led to the removal of the nasal cannula, which was not reported as the resident remained stable.
The facility failed to properly store medications, with pills, eye drops, ointments, and nasal sprays found at the bedside of four residents, and an expired eye drop on a medication cart. The ADON confirmed that residents are not allowed to keep medications in their rooms, and the facility's protocol requires nurses to remove any medications found and educate residents and their families. Staff members were unaware of the expiration date of medications on the cart and failed to ensure proper storage.
The facility failed to follow infection control protocols in the laundry room, as lint traps in the dryers were not cleaned as required. The lint log showed inaccurate entries, with staff signing for times when they were not present, leading to improper record-keeping and infection control lapses.
Unauthorized Restraint Removal Trial Conducted Without Physician's Order
Penalty
Summary
The facility failed to implement quality of care and service related to a trial for the removal of restraints for one resident. The deficiency was identified when a trial removal of restraints was initiated without a physician's order for a resident who had been using a soft safety belt while in a wheelchair to maintain seating position and minimize the risk of falling. The resident, who had a diagnosis of cerebral infarction, was observed without the restraint during a trial period, but there was no physician's order to authorize this trial. The resident's care plan included the use of the safety belt, and the trial was conducted to assess if the resident's risk for falls had changed. The MDS coordinator did not code the restraint in the Quarterly MDS because the resident was observed without the belt during the trial period. However, the trial was conducted without a stop date for the existing order of the safety belt, and the physician was only informed after the trial was completed. The Assistant Director of Nursing acknowledged that the doctor should have been notified and that the care plan did not reflect the trial. The facility's policy related to restraints and quality of care was not specific, and there was no specific policy for quality of care.
Failure to Adhere to Safety Policy Regarding Shaving Razors
Penalty
Summary
The facility failed to provide a safe environment for a resident, identified as Resident #46, by allowing the presence of four disposable shaving razors on the resident's nightstand. This was observed during a survey on 11/18/24. Resident #46, who was awake and alert, stated that they shave themselves and that the staff provides them with the razors. According to the facility's policy, residents are not permitted to keep razors in their rooms for safety reasons. The policy requires that razors be given to residents by Certified Nursing Assistants (CNAs) when needed and disposed of in a sharps container after use. However, this policy was not followed in the case of Resident #46. Resident #46 was admitted with a diagnosis of Angina Pectoris and had a Brief Interview for Mental Status score indicating no cognitive impairment. The resident was independent with personal hygiene, including shaving, and had a care plan addressing hoarding behavior. Despite this, the facility's staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that razors should not be kept in residents' rooms. The presence of razors in Resident #46's room indicates a lapse in adherence to the facility's safety precautions and procedures, as outlined in their policy.
Failure to Administer Prescribed Oxygen
Penalty
Summary
The facility failed to administer oxygen as prescribed for a resident, identified as Resident #83, who was observed without oxygen in progress despite having a physician's order for continuous oxygen at a rate of two liters per minute. Observations included the resident lying in bed with the nasal cannula placed on a pillow and participating in activities without oxygen. The resident's care plan indicated a need for continuous humidified oxygen via nasal cannula due to altered respiratory status and difficulty breathing, with a goal to prevent signs or symptoms of poor oxygen absorption. Interviews with staff revealed a lack of awareness and communication regarding the resident's need for continuous oxygen. A registered nurse noted that the resident often removed the nasal cannula due to confusion but did not report these incidents as the resident remained stable. A certified nursing assistant was unaware of the requirement for continuous oxygen use. The Assistant Director of Nursing stated that residents with continuous oxygen orders should not be without it except during personal care, and any removal of the nasal cannula should be documented and reported to a doctor. The facility's policy on oxygen therapy required starting the oxygen flow at the prescribed rate and ensuring the delivery device was on the resident.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications for four residents and one medication cart, as observed during a recertification survey. Medications, including pills, eye drops, ointments, and nasal sprays, were found at the bedside of four residents. Additionally, an expired Moxifloxacin eye drop was found on one of the medication carts. The Assistant Director of Nursing (ADON) confirmed that residents are not allowed to keep medications in their rooms, and the facility's protocol requires nurses to remove any medications found and educate residents and their families. The surveyor's observations revealed that the facility's staff did not adhere to the established protocols for medication storage. Staff members, including a Registered Nurse (RN), were unaware of the expiration date of medications on the cart and failed to ensure that medications were stored securely and properly. The Director of Nursing (DON) stated that medications should be kept in locked medication rooms and carts, and nurses are responsible for checking for expired medications and ensuring that no medications are left at residents' bedsides.
Infection Control Lapse in Laundry Room
Penalty
Summary
The facility failed to adhere to infection control protocols in the laundry room, as observed during a survey. The surveyor noted that the lint traps in the laundry room's dryers were not cleaned as required. The lint log, which is supposed to be signed every two hours by the laundry staff, indicated that the traps were last cleaned at 7:00 AM on the day of the survey. However, upon inspection, both lint traps were found to be full of lint, suggesting that they had not been cleaned as per the schedule. Further investigation revealed discrepancies in the logging process. The laundry staff, who start their shift at 6:00 AM, were found to be signing the log for 5:00 AM, a time when no staff were present in the laundry room. This was confirmed by the Maintenance and Housekeeping Director, who acknowledged that the staff had been signing for 5:00 AM due to using an outdated log sheet. This practice led to inaccurate record-keeping and a failure to maintain proper infection control measures in the laundry room.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kendall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palace At Kendall Nursing And Rehabilitation Cente | 2.8 mi | ★★★★★ | 6 | 0 |
| Harmony Health Center | 4.1 mi | ★★★★★ | 0 | 0 |
| Coral Reef Subacute Care Center Llc | 5.4 mi | ★★★★★ | 1 | 0 |
| South Dade Nursing And Rehabilitation Center | 6.2 mi | ★★★★★ | 5 | 0 |
| St Annes Nursing Center, St Annes Residence Inc | 6.6 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.